Recurrence after transanal endoscopic microsurgery for benign and malignant rectal tumours: experience of a single New Zealand centre

BACKGROUND

Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours.

METHODS

We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates.

RESULTS

We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths.

CONCLUSION

Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

The Outcome of Local Excision of Rectal Adenomas with High-Grade Dysplasia by Transanal Endoscopic Microsurgery: A Single-Center Experience

Background: Local excision by transanal endoscopic microsurgery (TEM) is considered an acceptable treatment for rectal adenomas with high-grade dysplasia (HGD). This study aims to assess the likelihood of harboring an invasive carcinoma in preoperatively diagnosed HGD polyps and evaluate the risk factors for tumor recurrence in patients with final HGD pathology. Methods: Data from patients who underwent TEM procedures for adenomatous lesions with HGD from 2005 to 2018 at the Rabin Medical Center, Hasharon Hospital, were analyzed. Collected data included patient demographics, preoperative workup, tumor characteristics and postoperative results. Follow-up data including recurrence assessment and further treatments were reviewed. The analysis included two subsets: preoperative pathology of HGD (sub-group 1) and postoperative final pathology of HGD (sub-group 2) patients. Results: Forty-five patients were included in the study. Thirty-six patients had a preoperative diagnosis of HGD, with thirteen (36%) showing postoperative invasive carcinoma. Thirty-two patients had a final pathology of HGD, and three (9.4%) experienced tumor recurrence. Large tumor size (>5 cm) was significantly associated with recurrence (p = 0.03). Conclusions: HGD rectal polyps are associated with a significant risk of invasive cancer. Tumor size was a significant factor in predicting tumor recurrence in patients with postoperative HGD pathology. The TEM procedure is an effective first-line treatment for such lesions.

Comparison between Endoscopic Submucosal Dissection and Transanal Endoscopic Microsurgery in Early Rectal Neuroendocrine Tumor Patients: A Meta-Analysis

PURPOSE

To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal neuroendocrine tumor (RNET) patients. This article will provide reliable evidence for surgeons in regards to clinical decision-making.

METHODS

Systematic literature retrieval was performed in Pubmed, Embase and Cochrane database from 2013/4/30 to 2023/4/30. Methodology validation was performed by using the Newcastle-Ottawa Scale (NOS). Data-analysis was conducted by using the Review manager version 5.3 software.

RESULTS

A total of three retrospective studies were included in our meta-analysis. All eligible studies were considered to be high quality. By comparing baseline characteristics between TEM and ESD, patients in the TEM group seemed to be characterized by a larger tumor size and lower tumor level, even though no statistical significance was found. Clear statistical significance favoring TEM was identified in terms of R0 resection rate, procedure time and hospital stay. No statistical significance was found in terms of recurrence rate, adverse events rate and additional treatment rate.

CONCLUSIONS

Compared with ESD, TEM was a more effective treatment modality for early RNET patients; it was associated with a relatively higher R0 resection rate and a similar degree of safety. However, the relatively higher cost and complicated manipulation restricted the promotion of TEM. Surgeons should opt for TEM as a primary treatment in patients with a larger tumor size and deeper degree of tumorous infiltration if the financial condition and hospital facility permit.

The outcome of local excision of large rectal polyps by transanal endoscopic microsurgery

Introduction

Local excision of large rectal polyps can be an alternative for radical rectal resection with total mesorectal excision. We aim to report the functional and oncological outcomes of transanal endoscopic microsurgery (TEM) for patients with large rectal polyps.

Methods

All demographic and clinical data of patients who underwent TEM for rectal polyp of 5 cm or more at the Hasharon Hospital from 2005 to 2018 were retrospectively reviewed.

Results

Twenty-eight patients were included. The mean age was 66 years. The mean polyp size was 6.2 cm (range: 5-8.5 cm) with a mean distance of 8.3 cm from the anal verge. Peritoneal entry during TEM was observed in five patients and additional laparoscopy after the completion of the TEM was performed in four patients. There were no major perioperative complications. Seven patients had minor complications. Final pathology revealed T1 carcinoma in five patients and T2 carcinoma in three patients. Re-TEM was performed in one patient with involved margins with adenoma. After a median follow-up of 64 months, one patient had local recurrence.

Conclusion

TEM is an acceptable technique for the treatment of large polyps with minor complications and a reasonable recurrence rate. TEM may be considered regardless of the size of the rectal polyp.

Can we Save the rectum by watchful waiting or TransAnal surgery following (chemo)Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC)? Protocol for the international, multicentre, rolling phase II/III partially randomized patient preference trial evaluating long-course concurrent chemoradiotherapy versus short-course radiotherapy organ preservation approaches

AIM

Organ-saving treatment for early-stage rectal cancer can reduce patient-reported side effects compared to standard total mesorectal excision (TME) and preserve quality of life. An optimal strategy for achieving organ preservation and longer-term oncological outcomes are unknown; thus there is a need for high quality trials.

METHOD

Can we Save the rectum by watchful waiting or TransAnal surgery following (chemo)Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC) is an international three-arm multicentre, partially randomized controlled trial incorporating an external pilot. In phase III, patients with cT1-3b N0 tumours, ≤40 mm in diameter, who prefer organ preservation are randomized 1:1 between mesorectal long-course chemoradiation versus mesorectal short-course radiotherapy, with selective transanal microsurgery. Patients preferring radical surgery receive TME. STAR-TREC aims to recruit 380 patients to organ preservation and 120 to TME surgery. The primary outcome is the rate of organ preservation at 30 months. Secondary clinician-reported outcomes include acute treatment-related toxicity, rate of non-operative management, non-regrowth pelvic tumour control at 36 months, non-regrowth disease-free survival at 36 months and overall survival at 60 months, and patient-reported toxicity, health-related quality of life at baseline, 12 and 24 months. Exploratory biomarker research uses circulating tumour DNA to predict response and relapse.

DISCUSSION

STAR-TREC will prospectively evaluate contrasting therapeutic strategies and implement new measures including a smaller mesorectal target volume, two-step response assessment and non-operative management for complete response. The trial will yield important information to guide routine management of patients with early-stage rectal cancer.

[Results of total mesorectal excision and transanal endoscopic microsurgery for rectal adenocarcinoma with submucosal invasion]

OBJECTIVE

To analyze early and long-term outcomes after total mesorectal excision (TME) and transanal endoscopic microsurgery (TEM) in patients with T1 rectal cancer.

MATERIAL AND METHODS

A retrospective non-randomized comparative study included 2 groups of patients: group 1 - total mesorectal excision, group 2 - transanal endoscopic microsurgery. In the second group, total mesorectal excision was proposed for patients with tumor invasion depth pT1sm3 and/or lymphovascular invasion and/or low differentiation. If total mesorectal excision was performed as a salvage surgery, the patient was excluded from further analysis.

RESULTS

There were 156 patients with rectal adenocarcinoma pT1 between October 2011 and August 2019 (102 cases - TEM, 54 cases - TME). We excluded 10 patients from the TEM group due to salvage surgery. Duration of TEM was 40.0 (34; 50) min, TME - 139 (120; 180) min (p=0.00001). Postoperative hospital-stay was also significantly less in the TEM group (7 (6; 9) vs. 10 (7; 11) days, p=0.00001). Six (6.5%) patients in the TEM group and 1 (1.8%) patient in the TME group developed a local recurrence in pelvic cavity (p=0.1). There were no distant metastases. Disease-free 3-year survival was 92% after TEM and 96% after TME (p=0.058).

CONCLUSION

Transanal endoscopic microsurgery is a relatively safe alternative to total mesorectal excision for early rectal cancer.

Transanal Local Excision or Endoscopic Dissection for Benign and Large Lesions of the Rectum

Since the introduction of transanal endoscopic microsurgery, local excision of "early" rectal lesions has offered the possibility to reduce the invasiveness of treatment for the limited disease. Flexible endoscopy techniques allow today different alternatives consisting of endoscopic mucosal resection or endoscopic submucosal dissection. The first is a straightforward and relatively easy technique, but it prevents a correct pathological staging of the lesion due to fragmentation and the verification of disease-free margins. The second relies on operators' audacity depending on their increasing experience due to the limited progress in technology. What is the preferable technique today is questionable. All the methods have pros and cons. The future certainly will see the use of ideal systems, allowing the possibility of precision surgery for partial- or full-thickness excision, depending on intraoperative findings, and the extension above the rectosigmoid junction. Miniaturized flexible robotic devices may represent the solution for both issues.

The Role of Transanal Endoscopic Surgery for Early Rectal Cancer

Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.

Inflammatory cloacogenic polyp in an adolescent - case report and review of the literature

Inflammatory cloacogenic polyp is a rare lesion arising in the anal transitional zone. It is usually benign, but rare cases of malignant transformation are known. It is most commonly seen in the adult population from the fourth to the sixth decade of life, but it can be found among children and adolescents as well. The most common clinical symptoms include rectal bleeding and altered bowel habits, although some patients may be asymptomatic. Treatment involves transanal endoscopic microsurgery followed by a bowel regimen with stool softeners. We present the case report of a 14-year-old boy presenting with intermittent rectal bleeding in whom a polypoid lesion was found during digital rectal examination. The patient underwent proctosigmoidoscopy during which the suspicious lesion was removed by transanal endoscopic microsurgery and the histological diagnosis of inflammatory cloacogenic polyp was established. In the postoperative period, the patient was without any further problems. In this case report, we want to raise awareness of this rare diagnosis and emphasize its place in the differential diagnosis of rectal bleeding across all age groups.

Comparison of the efficacy of endoscopic submucosal dissection and transanal endoscopic microsurgery in the treatment of rectal neuroendocrine tumors ≤ 2 cm

INTRODUCTION

Currently, complete tumor resection is considered the most effective treatment for rectal neuroendocrine tumors (NETs). Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are recommended for rectalNETs ≤2 cm, but it is not clear which method is better. Thus, we evaluated the efficacy of ESD and TEM in the treatment of rectal neuroendocrine tumors (NETs) ≤ 2 cm.

METHODS

We conducted a single-centre retrospective cohort study between 2010 and 2021 of rectal NETs ≤ 2 cm in 114 patients with long-term follow-up data who were divided into ESD (n=55) and TEM groups (n=59). Our study assessed differences between groups in the complete resection rate of lesions, recurrence rate, surgical complications, procedure time, and length of hospital stay.

RESULTS

The co-primary outcomes were the complete resection rate of lesions and the recurrence rate. Compared to that in the ESD group, the complete resection rate was significantly higher in the TEM group (91.5% vs. 70.9%, p=0.005). The median follow-up time was 22 months in our study, and the follow-up outcomes suggested that the rates of recurrence were 1.8% (1/55) and 6.8% (4/59) in the ESD and TEM groups, respectively, with no significant difference between the two groups. The secondary outcomes of the evaluation were surgical complications, procedural time, and length of hospital stay. The rate of complications (gastrointestinal bleeding and perforation) was low in both the ESD (7.3%, 4/55) and TEM (5.1%, 3/59) groups. No difference in hospitalization duration was observed between the two groups in our study. However, the procedure time was significantly shorter in the ESD group than in the TEM group (27.5 min vs. 56 min, p<0.001).

CONCLUSIONS

Although the rate of complete resection in the TEM group was higher than that in the ESD group, there was no difference in recurrence rates between the two modalities during long-term follow-up. Depending on the qualities of the available hospital resources in the area, one of the two approaches can be adopted.

Long-term outcomes of open versus closed rectal defect after transanal endoscopic microscopic surgery

AIM

Management of the rectal defect after transanal endoscopic microsurgery (TEM) is a matter of debate. Data are lacking on long term outcomes and continence of patients with open or closed rectal defect. We sought to analyse these in a retrospective cohort study.

METHODS

Patients undergoing TEM via the Specialist Early Rectal Cancer (SERC) MDT between 2012 and 2019 were included from a prospectively maintained database. These were divided into two groups - open and closed, based on management of rectal defect. Patient demographics and outcomes, including pre- and postoperative oncological staging, morbidity, mortality, length of stay and faecal incontinence severity score (FISI) scores were assessed.

RESULTS

A total of 170 matched patients were included (70-open, 100-closed rectal defects). Short-term complications (bleeding, infection, urinary retention and infection, length of stay and pain) were 18.8% with no significant difference between the two groups (22% vs. 16%). Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus (p = 0.87) or stricture (p = 0.79) but a significant difference in post-TEMS FISI scores in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02).

CONCLUSION

There are pros and cons associated with both rectal defect management approaches. Long-term complications should be expected and actively followed up. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEM.

Transanal endoscopic microsurgery under spinal anaesthesia

Background

Transanal endoscopic microsurgery (TEM) is considered the procedure of choice for rectal adenomas non-amendable for endoscopic excision and for early rectal cancer. TEM may gain more importance in patients who are considered unfit for major surgery. The option of spinal anaesthesia may offer many advantages for patients undergoing TEM while maintaining the principles of complete tumour excision. The aim of this study is to report the outcome of patients undergoing TEM under spinal anaesthesia.

Methods

Demographic and clinical data pertaining patients undergoing TEM under spinal anaesthesia between 2004 and 2015 were retrospectively collected.

Results

A total of 158 TEM procedures were recorded in the study period. Twenty-three patients (15%) underwent the procedure under spinal anaesthesia and were included in the study; 13 of them were male and ten were female. The mean age of the patients was 69.1 ± 10.6 years. Seventeen (74%) rectal lesions were adenomas, two (9%) were adenocarcinoma and four (17%) had involved margins after polypectomy. The mean tumour size was 2.1 cm (range, 0.5-3). Distance from the anal verge was 7.7 ± 2.2 cm. Seventeen (74%) lesions were in the posterior wall. The operative time was 73 min (range, 46-108) No adverse anaesthesia-related events were recorded, and the post-operative pain was reduced. The median time of hospitalisation was 2 days (range, 1-4). No major complications were noted, and the minor complications were treated conservatively. The surgical margins were free of tumour in all cases.

Conclusion

TEM under spinal anaesthesia had short duration of surgery, no increase in operative and post-operative complications or hospital length of stay. Avoiding the use of general anaesthesia, in such challenging procedure, may open new opportunities for patients determined to be unfit for general anaesthesia.

Transanal endoscopic microsurgical submucosal dissection: Are there advantages over conventional ESD?

INTRODUCTION

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a technique that has been recently described for the treatment of large rectal adenomas and early rectal cancer. The purpose of our study is to compare TEM-ESD with flexible endoscopic submucosal dissection (ESD) in an experimental, ex vivo porcine model.

MATERIAL AND METHODS

We used TEM-ESD and flexible ESD to resect a total of 100 standardized 4 × 4cm lesions in an ex vivo porcine stomach model, performing 50 resections with each technique. Total procedure time, en bloc resection rate, injuries of the muscularis propria, perforation rate and learning curve were analysed.

RESULTS

TEM-ESD was associated with a significantly shorter total procedure time in comparison to ESD (19 min vs. 33 min, p < .001). The rates of en bloc resection, injury of the muscularis propria layer, and perforation were the same in both groups. The learning curve of TEM-ESD was shallower than that of ESD.

CONCLUSION

TEM-ESD showed an advantage over ESD in terms of procedure time and learning curve, with similar en bloc resection rates and safety profile in our experimental model.

Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer

AIM

Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment).

METHODS

We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes.

RESULTS

Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports.

CONCLUSION

These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment

AIM

Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation.

METHOD

Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology.

RESULTS

In all, 102 patients underwent LE. Ten patients were excluded (N = 92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P < 0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%).

CONCLUSION

Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.

Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

BACKGROUND AND AIM

Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question.

METHODS

A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared.

RESULTS

Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13).

CONCLUSIONS

In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.

Endoscopic management of rectal neuroendocrine tumours. How to avoid a mistake and what to do when one is made?

Rectal neuroendocrine tumours are subepithelial lesions that are potentially malignant. Although the biology of these lesions has become increasingly understood and their management has been established, the endoscopic management of these tumours remains controversial. Recent studies demonstrated that compliance with guidelines is poor, and the majority of rectal neuroendocrine tumours are removed by an improper method, making management more complex and putting patients at risk of metastatic spread. Thus, there is a need to educate physicians who care for patients with these disorders. Our review has some tips and pointers for preventing mistakes in primary treatment and salvage therapy after polypectomy.

Transanal Endoscopic Microsurgery for Rectal Neoplasms

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

Diagnosis and Management of Rectal Neuroendocrine Tumors (NETs)

Rectal neuroendocrine tumors (NETs) are rare, with an incidence of 0.17%, but they represent 12% to 27% of all NETs and 20% of gastrointestinal NETs. Although rectal NETs are uncommon tumors, their incidence has increased over the past few years, and this is probably due to the improvement in detection rates made by advanced endoscopic procedures. The biological behavior of rectal NETs may be different: factors predicting the risk of metastases have been identified, such as size and grade of differentiation. The tendency for metastatic diffusion generally depends on the tumor size, muscular and lymphovascular infiltration, and histopathological differentiation. According to the current European Neuroendocrine Tumor Society (ENETS) guidelines, tumors that are smaller than 10 mm and well differentiated are thought to have a low risk of lymphovascular invasion, and they should be completely removed endoscopically. Rectal NETs larger than 20 mm have a higher risk of involvement of muscularis propria and high metastatic risk and are candidates for surgical resection. There is controversy over rectal NETs of intermediate size, 10–19 mm, where the metastatic risk is considered to be 10–15%: assessment of tumors endoscopically and by endoanal ultrasound should guide treatment in these cases towards endoscopic, transanal, or surgical resection.

Oncological Outcomes of Transanal Endoscopic Microsurgery Plus Adjuvant Chemoradiotherapy for Patients with High-Risk T1 and T2 Rectal Cancer

Background: Radical surgery is recommended for high-risk pathological stage T1 (pT1) or pT2 rectal cancer after transanal endoscopic microsurgery (TEM). However, in clinical practice, many patients may unfit or decline radical surgery. In recent years, adjuvant chemoradiotherapy (CRT) after TEM was considered as an alternative to radical surgery for these patients. This study aimed to assess oncological outcomes of adjuvant CRT after TEM for high-risk early rectal cancer. Materials and Methods: We collected retrospectively data of 97 patients who underwent TEM with pT1 and pT2 between January 2008 and December 2018. Of these, 35 patients were excluded. Of the remaining 62 patients, 42 were managed by TEM alone and 20 by TEM plus adjuvant CRT. Demographics, recurrence, and survival were analyzed between the two groups. Results: At a median follow-up of 52.5 months, the 3-year local recurrence-free survival and disease-free survival (DFS) in TEM alone group were significantly lower than those in TEM+CRT group (66.6% versus 93.3%, P = .035; 63.7% versus 93.3%, P = .022). Although the 3-year overall survival in TEM+CRT group was higher than TEM alone group (100% versus 83.3%), the difference was not statistically significant (P = .13). The local recurrence rate in TEM alone was 31%, compared with 5% in TEM+CRT group (P = .025). Multivariate analysis showed that adjuvant CRT was an independent prognostic factor for DFS (hazard ratio: 0.094; 95% confidence interval: 0.001-0.764; P = .027). Conclusions: Our study suggests that adjuvant CRT after TEM may be an alternative for pT1 high-risk and T2 rectal cancer who are not suitable or unwilling to undergo salvage radical surgery.

Can less be more? Organ preservation strategies in the management of rectal cancer

Background

Total mesorectal excision (tme) is the current standard of care for the treatment of rectal cancer. However, that surgery is associated with significant morbidity and mortality. Clinicians and patients are seeking alternatives to radical resection. Currently, prevalent organ-sparing strategies under investigation include local excision and nonoperative management (nom).

Methods

We reviewed the current evidence in the literature to create an overview of the use of transanal endoscopic surgery and watch-and-wait strategies in the modern management of rectal cancer.

Results

Compared with radical resection, transanal endoscopic surgery in patients with early rectal cancer (cT1) having favourable histopathologic features is associated with an increased risk of local recurrence, but no difference in 5-year survival. In patients with T2 or early T3 cancer, strategies that use neoadjuvant or adjuvant therapy as adjuncts to local excision are under evaluation. Nonoperative management is a new option for patients who experience a complete clinical response after neoadjuvant chemoradiotherapy (ncrt). The selection criteria that will appropriately identify patients for whom nom will succeed are not established.

Conclusions

Local excision is appropriate for early rectal cancer with favourable histopathologic features. Although organ-preserving strategies are promising, the quality of the evidence to date is insufficient to replace the current standard care in most patients. Patients should be offered nom in the safe setting of a clinical trial or registry. Rigorous follow-up, including endoscopy and imaging at frequent intervals is recommended when radical resection is forgone.

Minimizing the surgical approach for a rare disease: transanal endoscopic microsurgery for rectal schwannoma

OBJECTIVE

Rectal schwannomas are extremely rare tumors and their surgical treatment is widely variable in literature. Transanal endoscopic microsurgery (TEM) approach could be a reasonable option for such lesions, offering an organ-sparing strategy, but evidence is scarce.

METHODS

We report a 69-year-old man with a rectal submucosal lesion at 10 cm from the anal verge, treated by TEM. A systematic literature review on surgical approaches in rectal schwannoma was performed.

RESULTS

The patient was successfully treated by TEM, with adequate excision of the submucosal lesion. Histopathology revealed a rectal schwannoma. No recurrence was found at 1-year endoscopic follow-up. Previous studies reported 23 cases of rectal schwannoma and several treatment options, but only 2 cases were treated by TEM. Anterior rectal resection was generally adopted in cases of large, symptomatic masses with inconclusive preoperative biopsy, while lesions with features suggestive of stromal tumors were preferentially treated by endoscopy or, if located in distal rectum, by transanal approaches.

CONCLUSIONS

An organ-sparing minimally invasive approach should be the standard of care for rectal schwannomas. TEM could extend the indication for their endoscopic treatment, providing adequate excision even for larger schwannomas of the middle-upper rectum.

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

AIM

Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME.

METHODS

From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared.

RESULTS

Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15).

CONCLUSION

Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.

Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study)

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.

Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer

BACKGROUND

Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.

MATERIALS AND METHODS

Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.

RESULTS

One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.

CONCLUSION

Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

Radiotherapy May Offer a Recurrence and Survival Benefit in Rectal Cancers Treated Surgically with Transanal Endoscopic Microsurgery: A Systematic Review and Meta-analysis

BACKGROUND/AIM

Several studies report outcomes of Transanal Endoscopic Microsurgery (TEMS) surgery in combination with radiotherapy, however the combination of those treatments is provided mostly on an adhoc individual basis and the role of radiotherapy remains unclear. The aim of this study was to identify the effect of neo-adjuvant or adjuvant radiotherapy in the oncological outcomes of rectal cancer treated surgically with TEMS.

MATERIALS AND METHODS

We performed a systematic review of the literature on MEDLINE and Pubmed databases. Data were extracted by two independent reviewers and meta-analyzed using an inverse variance heterogeneity model to calculate overall (pooled) effect sizes for survival or recurrence of disease against neo+/-adjuvant treatment.

RESULTS

A total of 48 studies were included in the qualitative meta-analysis which included 3,285 patients with rectal cancer. The overall survival odds ratio (OR), was 9.39 (95% CI=6.1-14.4) with a Cochran's Q variable of 151.7 on 47 degrees of freedom (d.f.) (p=0.000). Recurrence-free OR was 8.7 (95%CI=6.58-11.44) with a Cochran's Q variable of Q=145.2 on 44 d.f. (p=0.000). Studies which contained more than 10% of pT3 tumours, and provided neo+/-adjuvant treatment in more than 35% of cases, were associated with survival benefit, as demonstrated by an overall odds of survival of 32.2 (95%CI=16.3-63.5, p=0.001, Q=8.4, p=0.21). Studies that contained more than 10% of pT3 tumours and provided neo+/-adjuvant treatment in more than 20% of the cases had an overall effect size of recurrence-free odds of 20.23 (95%CI=13.84-29.57, p=0.000, Q=2.18, p=0.54).

CONCLUSION

There seems to be a benefit from radiotherapy on overall survival and recurrence-free odds, which is more apparent in cohorts with more than 10% of pT3 tumours. Our results suggest that neo-adjuvant or adjuvant radiotherapy should be considered for inclusion in formal treatment protocols for rectal cancers treated with TEMS as they offer a recurrence and survival benefit.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer

Background and Objectives:

Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1–T2).

Methods:

Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data.

Results:

There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection.

Conclusions:

This study identified only a small number of T1–T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Comparison of efficacy and safety between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumor

BACKGROUND/AIM

To compare the treatment efficacy and safety between endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal epithelial tumors, including large adenoma, cancer, and subepithelial tumors (SET).

PATIENTS AND METHODS

We conducted a retrospective analysis of the medical records of 71 patients with rectal tumors who were treated with ESD (48 patients) or TEM (23 patients) from January 2013 to December 2015. The patient group comprised 56 patients with epithelial tumors and 15 patients with SET. Treatment efficacy such as en bloc resection, procedure time, local recurrence, hospital stay, additional procedure rate, and safety between the treatment groups were evaluated and analyzed.

RESULTS

There were no significant differences in tumor size, location, macroscopic appearance, and histological depth between ESD and TEM groups. For ESD compared to TEM in rectal epithelial tumors, en bloc resection rates were 95% vs. 93.7% and R0 resection rates were 92.5% vs. 87.5% (P = 0.617); in rectal SET, en bloc resection rates were 100% vs. 100% and R0 resection rates were 87% vs. 85% (P = 0.91). The procedure time was 71.5 ± 51.3 min vs. 105.6 ± 28.2 min (P = 0.016) for epithelial tumors and 32.13 ± 13.4 min vs. 80.71 ± 18.35 min (P = 0.00) for SET, respectively. Hospital stay was 4.3 ± 1.2 days vs. 5.8 ± 1.8 days (P = 0.001) for epithelial tumors and 4.1 ± 4.1 days vs. 5.5 ± 2 days (P = 0.42) for rectal SET, respectively. There were no significant differences between recurrence rates, additional procedure rates, and complications in the two groups.

CONCLUSIONS

ESD and TEM are both effective and safe for the treatment of rectal epithelial tumors and SET because of favorable R0 resection rates and recurrence rates. However, the ESD group showed shorter procedure times and hospital stays than the TEM group. Therefore, ESD should be considered more preferentially than TEM in the treatment of large rectal epithelial tumors and SET.

Comparison of transanal endoscopic microsurgery with or without neoadjuvant therapy and standard total mesorectal excision in the treatment of clinical T2 low rectal cancer: a meta-analysis

Some clinical trials demonstrated local resection for clinical T1 rectal cancer was safe and effective. But for clinical T2 rectal cancer, the results were controversial. Neoadjuvant therapy (NT) is proven to reduce the opportunity of advanced rectal cancer recurrence in various researches. The objective of this Meta-Analysis was to evaluate the oncological outcomes of transanal endoscopic microsurgery (TEM) with or without NT comparing with conventional total mesorectal excision (TME) for the treatment of clinical T2 rectal cancer.To search for the relevant studies, an electronic search was done from the databases of Pubmed, Embase, and the Cochrane Library in this meta-analysis. We compared the effectiveness of transanal endoscopic microsurgery with or without NT and standard total mesorectal excision in the treatment of T2 Rectal Cancer. 1RCT and 3nRCTs including 121 TEM patients (TEM + NT: 59, TEM: 62) and 174 TME patients with T2 rectal cancer were retrieved. Compared with TME, there were no significant differences in the outcomes of local recurrence, overall recurrence, overall survival between TEM + NT group. However in compassion with TME, TEM without NT was associated with an increased local recurrence, overall recurrence, and a shorter overall survival, with individual ORs being 3.04 (95% Cl: 1.17-7.90; I2 = 0%), 5.67 (95% Cl: 1.58-20.38; I2 = 0%) and 0.12 (95% Cl: 0.02-0.65; I2 = 0%), respectively. Compared with TME, TEM after NT may be a feasible and safe organ preservative approach for patients with clinical T2 low rectal cancer. But for those without NT, TEM always seem be associated with worse oncological outcomes.

Transanal Endoscopic Microsurgery for Patients with Rare Rectal Tumors

BACKGROUND

Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. Rare rectal tumors consist of several different types of malignant or benign tumors. Surgical management is considered to be the only curative option. The aim of this study is to investigate the role of TEM in the treatment of rare rectal tumors.

MATERIALS AND METHODS

A total of 147 patients with rare rectal tumors underwent TEM in our center from April 2006 to May 2017. Clinical data were collected and a retrospective accurate database was constructed. Demographic characteristics, operative details, tumor details, complications, and follow-up data were analyzed.

RESULTS

Seventy-eight patients were male. Mean tumor diameter was 1.2 ± 0.7 cm and mean distance from the anal verge was 6.6 ± 2.3 cm. Full-thickness and complete resection with negative margins was achieved in all patients. Complications occurred in 3 patients during surgery and in 20 patients after surgery. Histopathologic results were neuroendocrine tumors in 104 patients; gastrointestinal stromal tumors in 35; melanoma, lymphoma, and leiomyoma each in 2; lipoma, and squamous carcinoma each in 1. One hundred thirty-five patients were followed up for 49.3 ± 33.2 months. Two patients died, 1 had local recurrence and 1 had a rectovaginal fistula 1 month after surgery. No local recurrence or metastasis, or fecal incontinence was observed in the remaining patients.

CONCLUSION

TEM is an optimal treatment option for selected rare rectal tumors. The complication rate is low and the therapeutic effect is satisfactory.

Hybrid transanal and total mesorectal excision after transanal endoscopic microsurgery for unfavourable early rectal cancer: a report of two cases

Completion total mesorectal excision (TME) is a rare but complex procedure after transanal endoscopic microsurgery for early rectal cancer with unfavourable final histology. Two cases are reported when completion TME was performed after upfront transanal partial mesorectal dissection. Intact non-perforated TME specimens with negative and adequate distal and circumferential margins were created. The quality of both total mesorectal excisions was complete and distal margins were sufficient. We believe that our technique might be a way of approaching completion TME after TEM, especially in cases of low rectal cancer.

A modified sentinel lymph node technique combined with endoluminal loco-regional resection for the treatment of rectal tumours: a 14-year experience

AIM

After endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgey (TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision (NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME.

METHOD

A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme.

RESULTS

Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference (P = 0.0085).

CONCLUSION

NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates.

Local resection of rectal neuroendocrine tumor with first clinical manifestation of giant liver metastasis by transanal endoscopic microsurgery: A case report

RATIONALE

Rectal neuroendocrine tumor (NET) is a relatively rare tumor. Well-differentiated NETs (G1 and G2) rarely display distant metastasis at initial diagnosis. Currently, treatment for the primary lesions of rectal NETs with liver metastasis remains controversial. The liver metastasis was resected in local hospital. Transanal endoscopic microsurgery (TEM) has emerged as an effective minimally invasive surgery for local resection of lower rectal lesions. Herein, we reported the initial application of TEM to remove the rectal primary lesion in patients with low rectal NETs (G2) with giant liver metastases.

PATIENT CONCERNS

The patient, a 45-year-old woman, was primarily diagnosed with hepatocellular carcinoma and underwent curative resection of a giant liver lesion in a local hospital. Nevertheless, the postoperative pathologic examination revealed that the lesion was an NET (G2). The colonoscopy then showed a nodule 1.4 cm in diameter, 4 cm above the anal verge, located on the anterior wall of the rectum. The biopsy revealed that the nodule was also an NET (G2). However, the patient did not consent to abdominoperineal resection based on concerns for quality of life.

DIAGNOSES

Rectal NET with liver metastasis.

INTERVENTIONS

The patient underwent curative resection of liver metastasis. And, TEM was adopted to resect the primary tumor in rectum.

OUTCOMES

The patient has been disease-free for 2 years with a good quality of life and presents no local recurrence in the rectum.

LESSONS

TEM is an appropriate palliative operation for therapy of rectal NETs with distant metastases, especially for primary rectal NETs located in low rectal.

Local Excision and Endoscopic Resections for Early Rectal Cancer

Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.

Initial application of transanal endoscopic microsurgery for high-risk lower rectal gastrointestinal stromal tumor after imatinib mesylate neoadjuvant chemotherapy: A case report

RATIONALE

The lower rectal gastrointestinal stromal tumor (GIST) is a rare entity and warrants special attentions because of the considerations of preserving of anal and urinal functions. Neoadjuvant therapy with imatinib mesylate (IM) has achieved great success in GIST, which potentially extends the applications of function-preserving minimally invasive surgical procedures. Transanal endoscopic microsurgery (TEM) is a well-developed minimally invasive technique for benign tumors in lower rectum. Herein, we reported the initial application of TEM for high risk GIST after IM treatment.

PATIENT CONCERNS

A 52-year-old woman suffered mild lower abdominal pain and perianal discomfort. Physical examination found a soft mass 4 cm far away from anal verge. Rectal MRI and transrectal ultrasound (TRUS) showed that there was a 1.9 × 1.6 cm submucosal mass in the lower rectum. The incisional biopsy was performed and the pathological result reported it was a high-risk GIST.

DIAGNOSES

High-risk lower rectal GIST.

INTERVENTIONS

IM was given for neoadjuvant therapy. Then TEM was adopted to resect the residual tumor. IM was restored 4 weeks after surgery.

OUTCOMES

The final pathological results reported the margin was clear. After an 18-month follow up, no recurrence and metastasis was found and the patient had a satisfactory anal and urinal functions.

LESSONS

TEM in combination with IM could be a practical strategy for the high-risk lower rectal GIST simultaneously to achieve curative resection and to preserve the anal and urinal functions that can significantly improve the life quality of the patients.

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.

Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer

AIM

In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function.

METHOD

Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B).

RESULTS

In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment.

CONCLUSION

TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.

Transanal Minimally Invasive Surgery

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution

BACKGROUND

The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery.

METHODS

Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected.

RESULTS

141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively.

CONCLUSION

The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.

Management of Rectal Polyps

Colorectal cancer is one of the most common causes of cancer and cancer morbidity in the United States. In comparison to colon polyps, rectal polyps pose a unique challenge. Advances in endoscopic techniques have allowed for more thorough rectal adenoma detection and removal; however, there remains a concern over piecemeal resection and negative resection margins. Advances in transanal excision techniques, such as transanal endoscopic microsurgery, have been proposed for the removal of benign polyps as well as some early stage rectal cancers, with emphasis on proper patient selection. This review will discuss the current endoscopic and surgical considerations of both benign and malignant rectal polyps.

KRAS Mutant Status, p16 and β-catenin Expression May Predict Local Recurrence in Patients Who Underwent Transanal Endoscopic Microsurgery (TEMS) for Stage I Rectal Cancer

BACKGROUND/AIM

Transanal endoscopic microsurgery (TEMS) is emerging as an alternative treatment for rectal cancer Stage I. There remains a risk of local recurrence. The Aim of the study was to study the effect of biomarkers in local recurrence for Stage I rectal cancer following TEMS plus or minus radiotherapy.

MATERIALS AND METHODS

This is a case control study where we compared 10 early rectal cancers that had recurred, against 19 cases with no recurrence, total 29 patients (age=28.25-86.87, mean age=67.92 years, SD=14.91, Male, N=18, Female, N=11). All patients underwent TEMS for radiological Stage I rectal cancer (yT1N0M0 or yT2N0M0) established with combination of magnetic resonance imaging (MRI) and endorectal ultrasound. We prospectively collected all data on tumour histology, morphological features, as well as follow-up parameters. Molecular analysis was performed to identify their status on BRAF, KRAS, p16 O⁶-methylguanine-DNA methyltransferase (MGMT) and β-catenin.

RESULTS

Out of 29 specimens analyzed, 19 were KRAS wild type (65.9%) and 10 mutant (34.5%). Recurrence of the tumour was noted in 10 cases (34.5%) from which 60% were pT1 (N=6) and 40% pT2 (N=4). There was a statistically significant association between KRAS mutant status and local recurrence (N=6, p=0.037). P16 expression greater than 5% (mean=10.8%, min=0, max=95) is linked with earlier recurrence within 11.70 months (N=7, p=0.004). Membranous β-catenin expression (N=12, 48%) was also related with KRAS mutant status (p=0.006) but not with survival (p>0.05). BRAF gene was found to be wild type in all cases tested (N=23).

CONCLUSION

KRAS/p16/β-catenin could be used as a combined biomarker for prediction of local recurrence and stratification of the risk for further surgery.

Submucosal dissection has advantages over full-thickness transanal endoscopic microsurgery in selected rectal lesions

BACKGROUND

To establish the incidence of unsuspected malignancy in lesions excised through transanal endoscopic microsurgery (TEM) and examine the justification for full-thickness excision of all lesions thought to be benign pre-operatively.

METHODS

Demographic, operative and pathology data of all patients undergoing TEM at a single institution were collected in a prospectively maintained database. Follow-up data were collected with a focus on polyp recurrence rates and outcome in patients found to harbour malignancy. For lesions thought to be benign pre-operatively, a submucosal excision was routinely performed.

RESULTS

TEM was attempted in 156 cases between June 1999 and April 2013. Mean (standard deviation) patient age was 66.8 (2.1) years, with 111 males. Mean tumour size was 4.1 (1.6) cm, and mean height from anal verge was 10.4 (2.1) cm. In nine cases, the procedure was unable to be completed and in eight cases a deliberate full-thickness excision was performed. In 139 patients with a presumed benign lesion, mean operating time was 53.4 min. A total of 17 (12.2%) were found to harbour an unsuspected malignancy. Recurrent polyp was seen in 14 (11.7%) of 122 cases of benign pathology (mean follow-up 24.5 months) and was managed by endoscopic means in 10 patients. Mean length of stay was 1.2 days and complications occurred in 7% of cases. No patient with an unsuspected malignancy has developed recurrent disease (mean follow-up 43 months).

CONCLUSION

Submucosal TEM can result in low complication rates, short duration of surgery, short hospital stay and satisfactory recurrence rates when performed for presumed benign rectal tumours.

Successful repair of recurrent rectovaginal fistula by stratified suture using transanal endoscopic microsurgery: A CARE-compliant case report

BACKGROUND

Rectovaginal fistulas (RVFs) are abnormal connections between the rectum and vagina. Although many surgical approaches to correct them have been attempted, management of RVFs still remains a challenge, especially for recurrent RVFs.

METHODS

In the present study, we report a case in a 22-year-old female with a chief complaint of obvious passages of flatus or stool through the vagina for 10 years. She had suffered a vaginal trauma from a violent accident 10 years prior, and gradually noticed the uncontrollable passage of gas or feces from the vagina 2 weeks later.The patient underwent a transvaginal direct repair surgery at local hospital 9 years ago, but the symptoms recurred 1 month after the surgery. After 2-years monitoring, the patient underwent another transvaginal repair surgery (fistulectomy followed by direct suture) at another hospital, but the fistula recurred again. We initially performed a temporary protective transversostomy upon admission. After 8-months of observation, a methylene blue test was conducted and the diagnosis of recurrent RVF was confirmed. Subsequently, we performed a successful repair by stratified suture using transanal endoscopic microsurgery (TEM). The scar tissue on the posterior wall of the vagina and the anterior wall of the rectum were meticulously excised until the margin of the excisional line showed healthy tissue. In addition, the fistulous tract was completely removed. The edges of the fistula on the posterior wall of the vagina were closed by simple continuous suturing, and the rectal anterior wall was sutured in the same manner.

RESULTS

During a 1-year follow-up period, the fistulae were not recurrent and no complication such as incontinences or rectal bleeding were found. The latest Wexner score was 3.

CONCLUSION

We present a case of successful treatment with stratified suture using TEM throughout the procedure. We strongly recommend this efficient and minimally invasive procedure for recurrent RVFs.

Transanal endoscopic microsurgery for giant circumferential rectal adenomas

AIM

Transanal endoscopic microsurgery (TEM) was originally invented by Buess et al. (Chirurg, 1984, 55, 677-80) for the treatment of infraperitoneal rectal adenomas. Its indications have progressively expanded to include larger and more advanced lesions. The aim of the study was to report the results of TEM used for the treatment of circumferential rectal lesions.

METHOD

We retrospectively reviewed the medical records of 17 consecutive patients [median age 69 (32-89) years; nine men] who underwent TEM for a circumferential rectal lesion in our department between September 2010 and January 2015.

RESULTS

The median distance from the anal verge was 4 (3-11) cm, the median longitudinal extent was 7 (3-10) cm and the median surface area was 75 (40-255) cm(2) . An end-to-end anastomosis without proximal bowel mobilization was completed endoscopically in all cases. The median operating time was 120 (40-240) min. Persistent, endoscopically uncontrollable endoluminal bleeding in one patient was successfully treated with a second TEM procedure. One patient underwent preoperative radiotherapy for adenocarcinoma detected at the preoperative assessment. Surgical histology showed a pT3 cancer in one patient who refused further surgery, a pT2 cancer in two who subsequently underwent abdominoperineal resection, a pT1 cancer in four and a ypT0 in one patient. All are at present free of disease. No patients developed faecal incontinence or urinary or sexual dysfunction. Four patients required endoscopic balloon dilatation for stenosis.

CONCLUSION

Transanal endoscopic microsurgery is a feasible and safe technique for large circumferential lesions with a satisfactory outcome. Preoperative staging may be inaccurate.

Transanal Approach to Rectal Polyps and Cancer

A transanal approach to rectal polyp and cancer excision is often an appropriate alternative to conventional rectal resection, and has a lower associated morbidity. There has been a steady evolution in the techniques of transanal surgery over the past 30 years. It started with traditional transanal excision and was revolutionized by introduction of transanal endoscopic microsurgery in early 1980s. Introduction of transanal minimally invasive surgery made it more accessible to surgeons around the world. Now robotic platforms are being tried in certain institutions. Concerns have been raised about recurrence rates of cancers with transanal approach and success of subsequent salvage operations.

Removal of gallstone from mesorectum after laparoscopic cholecystectomy - new indication for transanal endoscopic microsurgery technique

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for local excision of benign and malignant neoplasms in the rectum. Indications for this technique are constantly changing and extending. The aim of this study is to describe a case of a unique and innovative application of this surgical technique. A 72-year-old patient was admitted to the Clinical Department of General and Colorectal Surgery for elective resection of a tumor located in the perianal area using the TEM surgical technique. In August 2005 the patient underwent laparoscopic cholecystectomy due to symptomatic cholecystitis. From March 2011 the patient complained about ongoing sharp pain in the perianal and presacral area. Computed tomography revealed two oval areas approximately 30 mm in size to the right of the sigmoido-rectal region communicating with the colon lumen. Subsequently diverticulitis was diagnosed. The TEM technique was uniquely used to successfully remove the gallstone from the 72-year-old patient's presacral area.

Transanal endoscopic microsurgery for rectal adenomas: single center experience

INTRODUCTION

Transanal endoscopic microsurgery (TEM) is a method of choice for the local treatment of rectal adenomas. Though generally considered as a safe method, some authors have expressed skepticism about the anorectal function following TEM.

AIM

To review our experience in using TEM for removal of rectal adenomas. We focused on morbidity, local recurrence rates, and anorectal function following the operation.

MATERIAL AND METHODS

The study included 72 patients who underwent TEM for rectal adenomas from December 2009 to November 2014 at the Department of Surgical Oncology, National Cancer Institute. Of the 72 patients, 31 (43.1%) were lost in the follow-up. We recorded the demographics, operative details, final pathology, post-operative length of stay, post-operative complications, recurrences and functional outcome for each of the 41 (56.9%) remaining participants.

RESULTS

Of the 41 eligible patients, 19 (46.3%) were male and 22 (53.7%) were female. The mean age of our patients was 66.8 years. There were no intraoperative complications. In 4 (9.8%) cases, postoperative complications were observed - urinary retention (2 cases, 4.9%) and postoperative hemorrhage (2 cases, 4.9%). All complications were treated conservatively. There was a single case (2.4%) of adenoma recurrence during the follow-up period. The mean score of the FISI questionnaire was 7.6 ±9.2 (ranging from 0 to 36), and the mean Wexner score was 2.3 ±3.4 (ranging from 0 to 17).

CONCLUSIONS

Transanal endoscopic microsurgery in our experience demonstrated low complication and recurrence rates, and good functional results. We conclude that TEM is an effective and safe method for the treatment of rectal adenomas.

The first attempt in local excision of anorectal malignant melanoma using transanal endoscopic microsurgery

Anorectal malignant melanoma (AMM) is an uncommon malignancy that is thought to arise from melanocytes in the mucosa around the anorectal junction. AMM is commonly misdiagnosed, and definitive preoperative diagnosis is often difficult. The prognosis of AMM is relatively poor. Although radical resection is required for AMM, there is still no consensus at this moment on which surgical approach is preferred. We herein report a rare case of AMM which was treated by transanal endoscopic microsurgery (TEM) in combination with radiotherapy, which resulted in complete excision of the lesion without complications. The successful treatment for this AMM using TEM emphasizes the need to broaden its application in the treatment of various rectal lesions while preserving organ function and decreasing recurrence.

Case report of a traumatic rectal neuroma

Traumatic neuroma is a well-recognized complication of lower extremity amputation, yet has also been noted to occur elsewhere. We report a clinical case and English-language literature review of traumatic rectal neuroma, a well-known pathologic entity not previously reported in this anatomic location.