Endoscopic Treatment of Carpet-Like Adenomas of the Rectum

Endoscopic transanal resection of rectal adenomas using the urological resectoscope

OBJECTIVE

Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital.

METHOD

Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed.

RESULTS

Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections.

CONCLUSION

ETAR is simple and safe for managing rectal adenomas.

Endoscopic trans-anal resection of rectal tumours: critical appraisal of an interdisciplinary approach

OBJECTIVE

Endoscopic trans-anal resection (ETAR) is an accepted technique for treating benign rectal adenomas that relies on technical expertise with the urological resectoscope. We present our experience with ETAR in an interdisciplinary setting combining the decision-making of the colorectal surgeon with the technical skill of the urologist.

METHOD

Assessment of all patients with adenomas and their subsequent care was organized by the colorectal team. Those with carpet-like rectal adenomas were referred to the urologist for ETAR performed using a Storz-Olympus 27/28Ch resectoscope, with roller-ball for haemostasis and glycine for irrigation.

RESULTS

Twenty-four patients (43-93 years, median 71 years; 14 men and 10 women) underwent 51 ETAR procedures from 1999 to 2005, with a median of two (range 1-6) procedures per patient. Complete clearance was achieved on 25 occasions. Two intra-operative extra-peritoneal perforations occurred which were managed conservatively. There were four cases of postoperative haemorrhage, two of which required a repeat procedure to secure haemostasis. Four patients had postoperative pyrexia that settled with oral antibiotics. Mean tumour distance from the anal verge was 7 cm (range 2-12 cm); the mean tumour area was 8 cm(2) (range 3-20 cm(2)); the mean operating time was 34 min (range 15-60 min) and the mean hospital stay was 32 h (range 24-120 h).

CONCLUSION

An interdisciplinary approach to ETAR uses available clinical resources efficiently as the colorectal surgeon does need to acquire the technical skills of endoscopic resection. Our results compare favourably with other published series and this approach can be adopted by any centre where colorectal and urological surgeons work together.

Transanal endoscopic micro-surgery (TEMS) for the management of large or sessile rectal adenomas: a review of the technique and indications

In this review article the surgical technique of Transanal Endoscopic Microsurgery (TEMS) is examined. A number of techniques have been used to treat adenomas of the rectum. The treatment of large adenomas which occupy a large surface of the rectal lumen or adenomas which are flat and grow in a "carpet-like" fashion is particularly challenging. Major rectal surgery carries a risk of morbidity and mortality, particularly in elderly and unfit patients. Although local excision with transanal resection (TAR) and the Kraske sacral operation have been used in the past, during the last twenty years TEMS has become the method of choice for those lesions. TEMS is efficient and minimally invasive. The technique allows the patient to recover rapidly and the incidence of complications is much lower than that of major surgery. In case of recurrence the option of repeat TEMS or major surgery remain available. TEMS has been slow to gain popularity mainly for reasons of cost and steep learning curve but it is now an established procedure and a valuable therapeutic option which is particularly useful for elderly and unfit patients. Gastroenterologists should be aware of the nature and indications of TEMS in order to advise and refer selected patients with rectal adenomas accordingly.

Use of laser for rectal lesions in poor-risk patients

BACKGROUND

This study evaluates laser ablation of large polyps and cancer of the rectum in poor-risk surgical patients.

METHODS

We performed a retrospective review of treatment of rectal lesions with the neodymium yttrium aluminium garnet (Nd:YAG) laser. Biopsy was performed before the first and subsequent therapies. Large lesions were initially debulked by diathermy snare. Biopsies were performed on suspicious areas at follow-up after completion of therapy.

RESULTS

Three patients with unresectable rectal cancer had symptom control over a mean period of 15.7 months and 12 patients with large polyps over 60.6 months since the start of therapy. Indications in polyps were carpeting of the rectum (n = 3), proximity to sphincter (n = 1), or comorbidity (n = 8). No complication occurred; however, there was 1 treatment failure. None of the patients with polyps developed cancer during a mean follow-up interval of 14 months after final treatment.

CONCLUSIONS

Outpatient laser therapy is safe, repeatable, and effective in the local control of rectal lesions.

Outcome of argon beam and LASER ablation of large rectal adenomas

OBJECTIVE: Endoscopic ablation of large rectal adenomas is being increasingly used as primary treatment. Despite the avoidance of general anaesthesia and the prevention of more major procedures, patients undergoing endoscopic ablation have the disadvantage of multiple treatment sessions and the lack of adequate tissue sample for complete histological study. The aim of this study was to analyse the outcome of all patients with large rectal polyps treated with endoscopic ablation. PATIENTS AND METHODS: Between 1993 and 1998, 29 patients who underwent endoscopic ablation of large rectal adenoma were identified. All their case notes were analysed and information was collected on recurrence, treatment episodes, complications, the incidence of carcinoma and the necessity for further procedures. RESULTS: At a median 40 (range 4-67) months follow-up, 41% of patients had recurrence of their adenoma and 14% had been diagnosed with adenocarcinoma. Only 24% of patients had been discharged while 21% were clear but were still under surveillance. Seven (24%) patients had complications, 6 stenosis and one severe bleeding. All stenosis occurred in patients who had more than 10 treatment sessions. In all, 31% of patients needed further endoanal or abdominal surgery and the median time to making this decision was 28 (range 4-66) months. There were no deaths. CONCLUSION: Laser and argon ablation of large rectal adenomas has proved very disappointing. It should be reserved for patients who are unfit to undergo general anaesthesia.