Transanal full-thickness excision of rectal tumours: should the defect be sutured? a randomized controlled trial

Local excision after neoadjuvant chemoradiotherapy for mid and low rectal cancer: a multicentric French study from the GRECCAR group

AIM

A complete or subcomplete tumour response (CTR) is observed in 10%-25% of patients with mid/low rectal cancer after neoadjuvant chemoradiotherapy (CRT). The aim of our study was to report a multicentric French experience in local excision (LE) after CRT.

METHOD

All patients who underwent LE for mid/low rectal cancer with suspected CTR after CRT, from 2006 to 2019 in seven GRECCAR centres were included. LE was considered adequate if the specimen showed a ypT0/Tis/T1R0 tumour, otherwise, a completion total mesorectal excision (TME) was discussed. Morbi-mortality, functional results and oncological outcomes were studied.

RESULTS

A total of 257 patients were included. LE specimens showed 36% ypT0, 4% ypTis and 19% ypT1. Thus, 108 patients (42%) had theoretical indication of completion TME, which was performed in only 42 patients. Overall, 30-day morbidity after LE was 11%, including 2% Clavien-Dindo grade III or IV complications. After completion TME, 47% described major low anterior resection syndrome versus 5% after LE alone (p < 0.001). After a mean follow-up of 4 years (range 2-6 years), the recurrence rate was 11% after LE, 32% after completion TME and 20% in patients for whom completion TME was indicated but not performed (p = 0.021).

CONCLUSION

TME remains the gold standard for mid/low rectal cancer after CRT. LE in selected patients is safe for operative and functional, but also oncological, results. However, completion TME was indicated in 42% of patients after LE, highlighting the difficulty of the preoperative diagnosis of CTR after CRT.

[Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]

Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

Transanal full-thickness excision for rectal neoplasm: is it advisable to leave the defect open?

PURPOSE

After a full-thickness total wall excision of a rectal tumor, suturing the defect is generally recommended. Recently, due to various contradictory studies, there is a trend to leave the defects open. Therefore, this study aimed to determine whether leaving the defect open is an adequate management strategy compared with suturing it closed based on postoperative outcomes and recurrences.

METHODS

A retrospective review of our prospectively maintained database was conducted. Adult patients who underwent transanal surgery for rectal neoplasm in our institution from 1997 to 2019 were analyzed. Patients were divided into two groups: sutured (group A) or unsutured (group B) rectal defect. The primary outcomes were morbidity (early and late) and recurrence.

RESULTS

In total, 404 (239 men) patients were analyzed, 143 (35.4%) from group A and 261 (64.6%) from group B. No differences were observed in tumor size, distance from the anal verge or operation time. The overall incidence of complications was significantly higher in patients from group B, which nearly double the rate of group A. With a mean follow-up of 58 (range, 12-96) months, seven patients presented with a rectal stricture, all of them from group B.

CONCLUSIONS

We acknowledge the occasional impossibility of closing the defect in patients who undergo local excision; however, when it is possible, the present data suggest that there may be advantages to suturing the defect closed.

Local full-thickness excision for sessile adenoma and cT1-2 rectal cancer: long-term oncological outcome

PURPOSE

We analyzed all patients who underwent local transanal surgery at our institution to determine oncological outcomes and perioperative risk.

METHODS

In 1997, we developed a prospective protocol for rectal tumors: transanal local full-thickness excision was considered curative in patients with benign adenoma and early cancers. In this analysis, 404 patients were included. To analyze survival, only those patients exposed to the risk of dying for at least 5 years were considered for the study.

RESULTS

The final pathological analysis revealed that 262 (64.8%) patients had benign lesions, whereas 142 had malignant lesions. Postoperative complications were recorded in 12.6%. At the median time of 21 months, 14% of the adenomas and 12% of cancers had recurred, half of which were surgically resected. The overall 5-year survival rate was 94%.

CONCLUSION

With similar outcomes and significantly lower morbidity, we found local surgery to be an adequate alternative to radical surgery in selected cases of early rectal cancer.

Complex Procedures in Transanal Endoscopic Microsurgery: Intraperitoneal Entry, Ultra Large Rectal Tumors, High Lesions, and Resection in the Anal Canal

Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.

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

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

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

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

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

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

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.

Management of intra- and postoperative complications during TEM/TAMIS procedures: a systematic review

INTRODUCTION

Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.

EVIDENCE ACQUISITION

A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.

EVIDENCE SYNTHESIS

A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.

CONCLUSIONS

Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

A multi-centre randomized controlled trial of open vs closed management of the rectal defect after transanal endoscopic microsurgery

AIM

Transanal endoscopic microsurgery (TEM) is a technically challenging strategy that allows expanded indications for local excision of rectal lesions. Transluminal suturing is difficult, so open management of the resultant defect is appealing. Expert opinion suggests there is more pain when the defect is left open. The aim of this study was to determine if closure of the defect created during full thickness excision of rectal lesions with TEM leads to less postoperative pain compared to leaving the defect open.

METHOD

At the time of surgery, patients undergoing a full thickness TEM were randomized to sutured (TEM-S) or open (TEM-O) management of the rectal defect. At five Canadian academic colorectal surgery centres, experienced TEM surgeons enrolled patients ≥ 18 years treated by full thickness TEM. The primary outcome was postoperative pain measured by the visual analogue scale. Secondary outcomes included postoperative pain medication use and 30-day postoperative complications, including bleeding, infection and hospital readmission.

RESULTS

Between March 2012 and October 2013, 50 patients were enrolled and randomized to sutured (TEM-S, n = 28) or open (TEM-O, n = 22) management of the rectal defect. There was no difference between the two study groups in postoperative pain on postoperative day 1 (2.8 vs 2.6, P = 0.76), day 3 (2.8 vs 2.1, P = 0.23) and day 7 (2.8 vs 1.7, P = 0.10).

CONCLUSION

In this multicentre randomized controlled trial, there was no difference in postoperative pain between sutured or open defect management in patients having a full thickness excision with TEM.

Assessing the safety and outcomes of repeat transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures.

METHODS

At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R).

RESULTS

Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group.

CONCLUSIONS

The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

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.

Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature

BACKGROUND

Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group).

METHODS

The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK).

RESULTS

Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups.

CONCLUSIONS

This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

Outcomes of Closed Versus Open Defects After Local Excision of Rectal Neoplasms: A Multi-institutional Matched Analysis

BACKGROUND

The management of the rectal wall defect after local excision of rectal neoplasms remains controversial, and the existing data are equivocal.

OBJECTIVE

This study aimed to determine the effect of open versus closed defects on postoperative outcomes after local excision of rectal neoplasms.

DESIGN

Data from 3 institutions were analyzed. Propensity score matching was performed in one-to-one fashion to create a balanced cohort comparing open and closed defects.

SETTINGS

This study was conducted at high-volume specialist referral hospitals.

PATIENTS

Adult patients undergoing local excision via transanal endoscopic surgery from 2004 to 2016 were included. Patients were assigned to open- and closed-defect groups, and further stratified by full- or partial-thickness excision.

INTERVENTION

Closure of the rectal wall defect was performed at the surgeon's discretion.

MAIN OUTCOME MEASURES

The primary outcome measured was the incidence of 30-day complications.

RESULTS

A total of 991 patients were eligible (593 full-thickness excision with 114 open and 479 closed, and 398 partial-thickness excision with 263 open and 135 closed). After matching, balanced cohorts consisting of 220 patients with full-thickness excision and 210 patients with partial-thickness excision were created. Operative time was similar for open and closed defects for both full-and partial-thickness excision. The incidence of 30-day complications was similar for open and closed defects after full- (15% vs. 12%, p = 0.432) and partial-thickness excision (7% vs 5%, p = 0.552). The total number of complications was also similar after full- or partial-thickness excision. Patients undergoing full-thickness excision with open defects had a higher incidence of clinically significant bleeding complications (9% vs 3%, p = 0.045).

LIMITATIONS

Data were obtained from 3 institutions with different equipment and perioperative management over a long time period.

CONCLUSIONS

There was no difference in overall complications between open and closed defects for patients undergoing local excision of rectal neoplasms, but there may be more bleeding complications in open defects after full-thickness excision. A selective approach to defect closure may be appropriate. See Video Abstract at http://links.lww.com/DCR/A470.

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis

BACKGROUND

Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed.

METHODS

Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0.

RESULTS

Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29).

CONCLUSIONS

This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance

AIM

Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centres. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM programme.

METHOD

All patients who underwent TEM at the Ottawa Hospital, Ottawa, Canada, between October 2009 and September 2014 were included. Data were abstracted through a retrospective chart review. The average rate of lesion excision (ARE) was calculated to standardize the operation time by size of the pathological specimen (min/cm³ ), representing a measure of surgical efficiency. Surgical efficiency was plotted using restricted cubic splines. Predictors of higher ARE were determined using multivariable regression.

RESULTS

During the study period 108 patients underwent TEM. ARE was available for 95 patients of mean age 67.2 years. The mean ARE was 18.6 min/cm³ . On adjusting for important covariates, the ARE improved with each additional case until 16 cases were completed. Significant predictors of higher ARE on multivariable analysis were age < 50 years, experience of fewer than five cases, and carcinoid/gastrointestinal stromal tumour or scar histology.

CONCLUSION

Operative efficiency appears to improve as surgeons completed 16 TEM cases. We have identified important factors that result in longer operating time. The study has important implications with regard to surgical training and operative planning for new TEM programmes.

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.

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

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

Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps

Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.

Transanal endoscopic surgery: past, present and future

Transanal endoscopic surgery is a safe, established technique to remove lesions in the rectum via the anus. This article reviews its evolution, approaches, indications and evidence for its role in treating benign rectal polyps. The future of transanal endoscopic surgery in rectal cancer and inflammatory bowel disease is also explored.

The surgical defect after transanal endoscopic microsurgery: open versus closed management

BACKGROUND

To determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured.

METHODS

This is a single-center cohort study using a prospectively maintained database. All patients ≥18 years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (<30 day postoperative) complications, including bleeding that required investigation and readmission, infection, and reoperation.

RESULTS

Between 2007 and 2014, data for all patients treated with TEM have been maintained in the St. Paul's Hospital TEM database. Overall, 236 patients had the TEM defect sutured (TEM-S) and 105 patients had the defect left open (TEM-O). There were no differences between the groups in patient age, gender, tumor size or underlying tumor histology. There was no difference in OR time between the groups, but the most experienced TEM surgeon performed significantly more of the TEM-S procedures (61 vs. 39 %, p < 0.01). There were 40 postoperative complications, affecting 11.7 % of the cohort. The complication rate was higher in the TEM-O group (8.4 vs. 19.0 %, p = 0.03). There was no statistically significant difference in bleeding complications (4.7 vs. 7.6 %, p = 0.27) or infections (2.1 vs. 6.7 %, p = 0.05). Readmissions were less common in the TEM-S group (4.7 vs 12.4 %, p = 0.01).

CONCLUSION

The St. Paul's Hospital TEM experience suggests that while it is safe to leave rectal defects open when a robust mesorectal fat layer is present, there appears to be fewer postoperative complications when the defect is sutured closed.

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

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

Postoperative complications in the treatment of rectal neoplasia by transanal endoscopic microsurgery: a prospective study of risk factors and time course

PURPOSE

Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia, but postoperative complications may be severe. We aimed to evaluate the risk factors related to the incidence, severity, and time course of postoperative complications of TEM.

METHODS

This is a prospective study of postoperative complications in 53 patients (>18 years old) with benign or early rectal neoplasia who underwent TEM with curative intention or, for higher stages, palliation. Outcome measures included age, sex, American Society of Anesthesiologists score, neoadjuvant chemoradiotherapy, lesion height and size, pathologic margins, tumor histology, and suture type.

RESULTS

Overall morbidity was 50 %. Temporary fecal incontinence was the most frequent complication (17.3 %). Complication rates of Clavien-Dindo grades I and II were 21.1 % and those of grades III and IV 3.8 %. Of patients with complications, more had lesions under the first rectal valve than over the first valve (61.54 % vs 38.46 %, p = 0.04). Patients submitted to chemoradiotherapy had a 24-fold greater chance of presenting grade II complications (p = 0.002). When the surgical defect was treated using the TEM device to perform the suture, the chance of having grade III complications was reduced 16-fold (p = 0.04). Fifty-three percent of complications occurred in the first 10 days and 95 % within 20 days.

CONCLUSIONS

Postoperative complications after transanal endoscopic microsurgery for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Over time the nature of complications is continuous, centered on the first 20 days after surgery.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer

BACKGROUND

Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT.

PATIENTS AND METHODS

This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared.

RESULTS

Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group.

CONCLUSIONS

With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.

[Management of complications in anal and transanal tumor surgery]

Anal and transanal tumor operations are safe and are associated with a very low morbidity. Perianal and anal lesions as well as low rectal tumors can be excised by direct exposure using an anal retractor. For lesions situated in the middle or upper third of the rectum, special instrumentation, such as transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) should be used to avoid unnecessary R1 resections. Fatal complications are extremely rare and most complications, such as urinary retention or temporary subfebrile temperatures, are minor. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant hemorrhage and opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suturing. Infections, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM

Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed.

METHOD

Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied.

RESULTS

Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16).

CONCLUSION

Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Study of anorectal function after transanal endoscopic surgery

AIM

To evaluate the impact of Transanal Endoscopic Microsurgery (TEM) on anorectal function, using clinical and manometric assessments. To identify subgroups likely to develop incontinence after TEM, by stratifying the sample.

METHOD

Descriptive, prospective study. Between December 2004 and May 2011, 222 patients were operated on at our hospital, of whom 21 were excluded from the study. Patients underwent anal manometry and answered a clinical incontinence questionnaire (the Wexner scale) prior to surgery, one month post-surgery, and then at four months post-surgery.

RESULTS

There were no statistically significant differences between preoperative Wexner questionnaire scores and values at one month and four months post-surgery. Preoperative baseline pressure (BP) values were 64 mmHg±26.18, falling to 44.26 mmHg±20.11 at one month and to 48.86 mmHg±21.14 at four months. Voluntary Contraction Pressure (VCP) reached preoperative values of 200.49 mmHg±88.85, falling to 169.5 mmHg±84.95 and to 173.6±79 at four months. The differences in BP and VCP were statistically significant. The sample was stratified in order to identify subsets susceptible to incontinence after surgery, but no at-risk subgroups were found. Multivariate analysis did not detect any predictors of incontinence.

CONCLUSION

The sustained, controlled anal dilatation produced with TEM caused statistically significant decreases in VCP and BP one month and four months after surgery. However, the Wexner questionnaire scores did not show any association with clinical incontinence. No predictors of postoperative incontinence were observed. We conclude that TEM is a safe technique and does not affect continence.

Use of self-retaining barbed suture for rectal wall closure in transanal endoscopic microsurgery

BACKGROUND

The aim of this study was to investigate the safety and efficacy of self-retaining barbed sutures in comparison with monofilament clip-fixated sutures for rectal wall closure in transanal endoscopic microsurgery.

METHODS

Horizontal full-thickness wall defects (3.5 cm) of cattle rectal specimens were closed via transanal endoscopic microsurgery using a monofilament suture with clips at the end (Surgipro(®) 2/0; Covidien, Mansfield, MA, USA, n = 25) or a self-retaining barbed suture (V-Loc™ 180 3/0; Covidien, Mansfield, MA, USA, n = 25). The primary endpoint was the pneumatic leakage pressure of the suture line. As a secondary endpoint, suture time was evaluated.

RESULTS

The median pneumatic leakage pressure for barbed sutures was 45.5 mbar (range 17-106 mbar) and 33.5 mbar (range 19-106 mbar) for monofilament sutures (p = 0.58). A pneumatic leak at a critical pressure below 25 mbar occurred in 3 cases with barbed sutures and in 7 cases with monofilament sutures (p = 0.29). Median suturing time [19:25 min:s (range 12:00-33:30) vs. 20:41 (17:00-28:33), p = 0.23] did not differ between the two groups.

CONCLUSIONS

Barbed sutures display the same bursting pressure as monofilament sutures and their use for rectal wall closure seems feasible.

[Transanal endoscopic operations for rectal tumours]

BACKGROUND

Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity.

METHODS

In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…).

RESULTS

The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients.

CONCLUSIONS

TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.

Transanal single-port access microsurgery (TSPAM)

Transanal single-port access microsurgery (TSPAM) is an emerging and feasible minimally invasive method for the transanal excision of large sessile adenomas and early-stage carcinomas of the rectum. Here we present our TSPAM experience on rectal adenomas (high-grade rectal adenomas in 5 cases and carcinoma in situ in 1 case). TSPAM is an innovative method that can be an affordable and disseminated alternative to transanal endoscopic microsurgery for the local excision of the rectal lesions.

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM: To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery (TEM).

METHODS: Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large (> 1 cm) polyps in the remaining rectum (range: 6-20 cm from the anal edge). All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maximum squeeze pressure, maximum tolerable volume (MTV) and rectoanal inhibitory reflexes (RAIR) were recorded. The integrity and thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life (QoL).

RESULTS: All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg (38 ± 5 mmHg vs 19 ± 3 mmHg, P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL (165 ± 19 mL vs 60 ± 11 mL, P = 0.000) at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg (38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057) and 159 ± 19 mL (165 ± 19 mL vs 159 ± 19 mL, P = 0.071), respectively, at month 6 after TEM. Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg (171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000) at week 2 after operation, and returned to normal values by postoperative month 3 (171 ± 19 vs 166 ± 18, P = 0.051). RAIR were absent in 4 patients preoperatively and in 12 (χ² = 4.947, P = 0.026) patients at month 3 after surgery. RAIR was absent only in 5 patients at postoperative month 6 (χ² = 0.141, P = 0.707). Endosonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm (1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm (1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239) at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm (3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm (3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123) at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 patients. With regard to the QoL, the physical and mental health status scores (SF-36) were 56.1 and 46.2 (50 in the general population), respectively.

CONCLUSION: The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.

Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer

AIM

The aim of the study was to determine the impact of primary full-thickness transanal excision (TAE) on the morbidity rate following radical rectal resection for cancer.

METHOD

Fourteen consecutive patients underwent radical resection for lower third rectal cancer following full-thickness TAE without closure of the defect. They were compared with 25 matched patients from a prospective database of 275 rectal resections who had undergone radical resection without previous TAE for lower third rectal cancer (control group). The confounding factors were: age, sex, body mass index (BMI), classification according to the American Society of Anaesthesiologists, administration of neoadjuvant radiotherapy before rectal resection, tumour stage and type of surgical procedure.

RESULTS

There were no deaths. Overall morbidity was 64.3% in the TAE group and 32% in the control group (P = 0.112). Surgical complications were significantly more frequent in the former (57.1%vs 20%; P = 0.048). The frequency of specific surgical site complications, including anastomotic complications and pelvic abscess formation requiring surgical drainage, was significantly higher in the TAE group than in the control group (42.8%vs 8%; P = 0.032). In univariate analysis, the only factors associated with specific surgical site complications were BMI > 27 and TAE before rectal resection.

CONCLUSION

This case-matched study suggests that previous full-thickness TAE increases the risk of surgical complications after radical resection for lower third rectal cancer, including anastomotic dehiscence and pelvic sepsis.

Transanal endoscopic microsurgery (TEM) for rectal tumor: the first French single-center experience

OBJECTIVE

Transanal endoscopic microsurgery (TEM) allows complete local excision of rectal tumor, especially in the middle and upper part of the rectum, and provides an alternative to conventional surgery. This is a report of the first French single-center experience to assess the feasibility and postoperative results for rectal tumor excised by TEM.

METHODS

From October 2007 to December 2008, 27 patients underwent TEM for excision of either rectal adenoma (n=19) or carcinoma (n=8). The median distance from the anal verge was 60mm (range: 10-140).

RESULTS

TEM excision was performed in 26/27 patients. Intraoperative technical difficulties were recorded in two patients (peritoneal perforation and gas leakage, respectively). The morbidity rate was 22% (n=6), including two patients (7%) with major complications (delayed rectal bleeding) requiring readmission to hospital for both, and surgical hemostasis for one. R0 resection rates for adenoma and carcinoma were 84% and 75%, respectively. Immediate salvage surgery was performed in one patient because of a T2R1 carcinoma. At the time of the median follow-up at nine months (range: 2.5-17.5), no patient had experienced a recurrence.

CONCLUSION

TEM is a safe and effective procedure with low morbidity for local rectal tumor resection. It allows local excision of benign tumors, especially those that are inaccessible to conventional local surgery resection, thereby avoiding radical surgery. In cases of carcinoma, its role in local surgery remains controversial and is yet to be defined.

Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors

BACKGROUND

Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal villous adenomas and early anorectal adenocarcinomas. It has been used clinically in many areas outside of China for more than 20 years, but it began in mainland China only about 2 years ago. Some articles have reported excellent results with regard to morbidity and relapse rate with TEM, but there are no studies addressing its functional results in China until now. The aim of the present study was to analyze the effect of TEM on the manometric results.

METHODS

Thirty-seven patients (16 females, 21 males) underwent TEM and were followed for more than 6 months. Anorectal manometry and an incontinence questionnaire were administered 1 week preoperatively, 2 weeks postoperatively, 3 and 6 months postoperatively.

RESULTS

Of the 37 patients, 24 had villous adenomas and 13 had adenocarcinomas (11 uT1 and 2 uT2). Anorectal manometric values showed the mean anal resting pressure (ARP) decrease from 45 +/- 6 mmHg to 29 +/- 4 mmHg (p < 0.05) and the maximum tolerable volume (MTV) decrease from 175 +/- 21 ml to 90 +/- 15 ml (p < 0.05) at the third month after TEM. Maximal squeeze pressure (MSP) decreased from 181 +/- 20 mmHg to 92 +/- 14 mmHg (p < 0.05) at second week after operation and returned to normal value by the third postoperative month. The ARP and MTV were 45 +/- 5 mmHg and 177 +/- 21 ml, respectively, at 6 months after TEM, near the normal value (p > 0.05). Rectoanal inhibitory reflex (RAIR) was absent preoperatively in two patients; it was also absent in 10 patients 3 months postoperatively and in three patients 6 months postoperatively. Endosonography demonstrated internal anal sphincter (IAS) rupture in five patients, and full integrity of the external anal sphincter (EAS) in all patients. Of the five patients with IAS rupture, four had temporary incontinence to flatus normalized up to three postoperative months. Most patients had more times of stools per day and relative higher Wexner scores in a short period after TEM. All these patients were followed for 6-20 months with no incidence of relapse.

CONCLUSIONS

Anorectal function was preserved well after TEM, although some anorectal manometric parameters changed over time. Thus TEM is safe, in terms of anorectal function, for the cure of benign and early malignant tumors of the rectum.

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background

Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications.

The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.

Methods/design

Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment.

Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures.

Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group.

Discussion

The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas.

Trial registration number

(trialregister.nl) NTR1422

Local full-thickness excision as first line treatment for sessile rectal adenomas: long-term results

OBJECTIVE

Removing rectal adenomas not only relieves symptoms, but also eradicates the incidence of carcinoma. There are many techniques for local removal of rectal polyps. Transanal endoscopic microsurgery (TEM) is the most recent. The purpose of this study is to present our long-term results using TEM for rectal adenomas, paying special attention to the risk factors of harboring a malignancy.

METHODS

Data from all patients undergoing TEM from December 1995 to December 2005 were collected prospectively. The selection criteria were benign sessile adenomas below the peritoneal reflection. In the study period, 173 patients were operated on for an apparently benign rectal adenoma. The mean distance of lower tumor was 7.6 cm (range, 1-18 cm), and the mean distance to upper edge was 11 cm (2-20 cm). Full-thickness local excision was performed in all procedures. Patients were followed for a minimum of 1 year.

RESULTS

According to the histologic findings, 14% of the specimens were invasive carcinomas. No statistical differences were found when comparing the histologic findings by tumor size, distance to the anal verge, or location.In 10 (5.8%) cases, the dissection was considered uncompleted because of a normal mucosa margin smaller than 1 mm. The mean hospital stay was 4 days (2-30 days). The morbidity rate was 14.5%. There was 1 postoperative death (0.6%). There were 9 (5.4%) histologically proven recurrences. Four of the patients with recurrence had uncompleted microscopic circumferential resection (P = 0.001). At a mean follow-up of 35 months (range, 12-82 months), all carcinoma patients were alive with no evidence of disease.

CONCLUSIONS

In conclusion, a significant number of adenomas that we assumed preoperatively to be benign were already carcinomas and we were unable to find any reliable predictor to identify them. TEM full-thickness excision provided a low rate of postoperative morbidity and potentially avoided a significant number of major abdominal operations and local recurrences.