A Large Rectal Submucosal Tumor in an Elderly Woman.

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.

External beam radiotherapy for synchronous rectal and prostatic tumors

While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors. Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R0) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I2statistics, and publication bias by funnel plot using Egger and Begg tests. Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I2 = 0.00%] and R0 resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I2 = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I2 = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I2 = 0.00%]. ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.

ABSTRACTElectrolyte depletion syndrome (EDS), also known as McKittrick–Wheelock syndrome, is a rare but life‐threatening condition caused by secretory diarrhea from colorectal villous tumors, often accompanied by severe electrolyte imbalances and renal dysfunction. Large, circumferential tumors have traditionally been managed with surgical resection, frequently requiring stoma formation. Recently, endoscopic submucosal dissection (ESD) has emerged as a minimally invasive alternative, although its feasibility for large rectal tumors remains limited. We report a case of EDS caused by a giant circumferential rectal villous tumor measuring approximately 28 cm, successfully treated with ESD. A 58‐year‐old man presented with persistent diarrhea, electrolyte disturbances, and acute kidney injury. Imaging and endoscopy revealed a circumferential villous tumor extending from the anal verge to the rectosigmoid colon, diagnosed as a villous adenoma without malignancy on biopsy. After careful discussion between the departments of gastrointestinal surgery and gastroenterology, ESD under general anesthesia was selected to avoid colectomy and stoma creation. En bloc resection of a 280 × 240 mm tumor was achieved without major complications. Prophylactic steroid injection and systemic steroid administration prevented post‐ESD stricture. Histopathology revealed adenocarcinoma with minimal submucosal invasion (800 µm), no lymphovascular invasion, and negative resection margins, indicating curative resection. At 6‐month follow‐up, no recurrence or stricture was observed. This case highlights the potential of ESD as a definitive and less invasive treatment option for EDS caused by large rectal villous tumors when performed with appropriate therapeutic planning and meticulous postoperative care.

Rectal mucosectomy, a technique adapted from restorative proctocolectomy, has been used to treat large rectal villous tumors. We compared morbidity, tumor control, and functional outcome following rectal mucosectomy with the results of more conventional transanal excision and piecemeal snaring and fulguration in patients with large rectal villous tumors. We retrospectively reviewed the charts of inpatients who had undergone transanal surgery for villous tumors. Between 1983 and 1993, rectal mucosectomy, transanal excision, and snaring and fulguration were performed, respectively, in 12, 26, and 23 patients with large rectal villous tumors. Tumors treated by rectal mucosectomy had a larger mean diameter (8.5 cm) than those treated by transanal excision or snaring and fulguration (4.5 cm and 4.2 cm, respectively; P < 0.0001, analysis of variance). After a mean follow-up of 47 months, incidence of tumor persistence was 17 percent following rectal mucosectomy, 20 percent following transanal excision, and 40 percent following snaring and fulguration (P = 0.04, chi-squared). Tumor recurrence was 8 percent after rectal mucosectomy compared with 36 and 44 percent, respectively, after transanal excision (P = 0.09, chi-squared) and snaring and fulguration (P = 0.04, chi-squared). Clinically significant postoperative bleeding did not occur after rectal mucosectomy; 17 percent of patients had persistent mild incontinence. Rectal mucosectomy for villous tumors, a new application of an established technique, is safe and associated with low rates of tumor persistence and recurrence. Rectal mucosectomy may result in mild incontinence and should be reserved for large or circumferential lesions. For smaller lesions, transanal excision results are more reliable tumor eradication than snaring and fulguration.

Small rectal carcinoid tumors (<10 mm) are often removed via endoscopic submucosal dissection (ESD). However, the use of ESD for tumors of an intermediate size (7-16 mm) is less well documented. This study aimed to evaluate the efficacy and safety of ESD compared with endoscopic mucosal resection using a cap (EMR-C) for the treatment of 7-16-mm rectal carcinoids. From September 2007 to August 2012, 55 patients with large rectal carcinoid tumors were treated by EMR-C (30 cases) or ESD (25 cases). The en bloc resection rate, pathological complete response (pCR) rate, procedure time, and incidence rates of complications, local recurrence, and distant metastasis were evaluated. The basic and clinical characteristics of the patients in the two groups did not differ significantly (p > 0.05). The mean procedure time was longer for ESD than EMR-C (24.79 ± 4.89 vs. 9.52 ± 2.14 min, p < 0.001). The rates of en bloc resection and pCR were higher with ESD than with EMR-C (100 vs. 83.33 %, and 100 vs. 70.00 %, respectively). No patients in the EMR-C group experienced complications. However, in the ESD group, two cases of perforation occurred, and one patient experienced delayed bleeding. These complications were successfully managed via endoscopical therapy. Five cases of local recurrence were detected after EMR-C, whereas no patients experienced recurrence after ESD. Compared with EMR-C, ESD appears to be a more favorable therapeutic option for the treatment of rectal carcinoid tumors less than 16 mm in diameter based on improved rates of pCR and local recurrence.

In the treatment of rectal stromal tumors, which account for approximately 5% of gastrointestinal stromal tumors, molecular-targeted neoadjuvant therapy should be considered if the tumor is too large to achieve R0 grade resection or multiple visceral resection is required. Currently, imatinib is generally recommended as the first-line agent for such therapy. Although it has been reported that neoadjuvant therapy in patients experiencing imatinib resistance or intolerable adverse events can be successfully achieved by switching to sunitinib, first-line use of sunitinib for neoadjuvant therapy of gastrointestinal stromal tumors has not previously been reported. In this case report, first-line sunitinib neoadjuvant therapy of two patients who had very large rectal stromal tumors at sites close to the prostate and bladder produced good clinical outcomes.

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for large rectal tumors. There are limited data available on stenosis rates following ESD of large rectal lesions. We aimed to evaluate the stenosis rate following ESD of large rectal tumors with rectal mucosal defectsgreater than three quarters of the circumference. We retrospectively identified patients who underwent rectal ESD between January 1998 and July 2014. Patientswith rectal mucosal defects greater than three quarters the luminal circumference were included for analysis. Clinicopathologic characteristics, treatment outcomes and adverse events were assessed. Stenosis was defined as an inability to pass a pediatric colonoscope into the sigmoid colon. None of the patients underwent prophylactic balloon dilation. A total of 363 patients with 370 rectal lesions were treated by ESD. Among these, 26 patients had 26 lesions with rectal mucosal defects greater than three quarters of the luminal circumference. Median tumor size (range) was 80 (47-150) mm. Four lesions (15%) required between 90 and <100% circumferential dissection, while complete circumferential ESD was performed in two lesions (8%). Dissection extended to the anal canal in six patients. The median procedure time was 220min. En bloc resection and curative resection were achieved in 88.5 and 65.4%, respectively. Delayed bleeding rates and perforation rates were 7.7 and 0%, respectively. During a median follow-up period of 9.8 (0-59) months, there were no patients with complaints of constipation or fecal incontinence. One patient (4.2%) was noted to have rectal stenosis, but was clinically asymptomatic. Endoscopic balloon dilation was not required in any patients. Stenosis may rarely occur after ESD of large rectal lesions with rectal mucosal defectsgreater than three quarters of the circumference, even without prophylactic endoscopic balloon dilation.

A 35 year old man visiting a hospital for his annual check-up in August 1992 was found to have a large rectal tumour on digital examination. Colonoscopy revealed a bulging lesion with normal mucosa. Endoscopic biopsy showed only normal tissue. Endoscopic ultrasonography demonstrated a large hypo-echoic submucosal tumour in the fourth layer (muscularis propria) of the rectal wall. Based on this endoscopic ultrasonographic finding, we diagnosed the tumour as leiomyoma pre-operatively. The tumour was excised by a trans-sacral local excision. The histological diagnosis of the resected specimen was cellular leiomyoma.

We report unusual two cases of local recurrence of villous tumor of the rectum after a transsacral excision, in which the recurrent tumor was situated outside the mucosal layer of the rectum. We believe that the lesion resulted from the implantation of tumor cells in the surgical track. Case 1: Involved a 72-year-old woman. Previous history disclosed that she underwent excision of a rectal villous tumors 30mm in diameter via transsacral approach. Histologically it was carcinoma in adenoma. Surgical cut end was positive for adenoma. Eight years after the primary operation, a 30×30×35mm mucinous adenocarcinoma was discovered in the rectal wall accompanied with peritoneal dissemination. Case 2: A 64-year-old man. He underwent an operation of a rectal villous tumor that was 40mm in diameter by a transsacral approach. Histology confirmed a well differentiated adenocarcinoma accompanied with no evidence of invasive malignancy. Surgical cut end was negative for adenoma and carcinoma. Three years and one month after the surgery, 40×40×35mm extrarectal adenocarcinoma was detected. It is probable that tumor cells sewn into the surgical stumups in Case 1 and the implantation of tumor cell sewn into the surgical stumps in Case 1 and the implantation of tumor cell during the first operation in Case 2 was responsible for the recurrence. And it is suggested that transsacral excision for the large rectal villous tumors with long diameter have a increased risk of developing a recurrence.

Neoadjuvant imatinib treatment, followed by complete transvaginal removal, presents a feasible option for large rectal gastrointestinal tumors located on the anterior wall of the rectum and protruding into the vagina. The use of Martius flap interposition is convenient and can be employed to prevent rectovaginal fistula.

We report a case of Stage IE mucosa-associated lymphoid tissue lymphoma arising in the rectum, which was successfully treated with radiotherapy. A 60-year-old man had several months of altered bowel habit with rectal bleeding and was found to have a large rectal tumor with no evidence of distant spread. Histologic studies showed this to be a mucosa-associated lymphoid tissue lymphoma. The patient received 45 Gy in 25 fractions with external beam radiotherapy during 5 weeks. The treatment was well tolerated and review at 41 months revealed no evidence of recurrence.

A 59-year-old cachectic male was referred to the surgical outpatient department with intermittent haematochezia and a longstanding change in bowel habit with associated weight loss and anaemia. Following investigation, he was diagnosed with a large rectal tumour with multiple metastases. 7 days later, the patient presented again with fevers, bilious vomiting, abdominal pain and distension. On examination, he had a generally tender abdomen,= although no peritonism, but an enlarged, extremely tender hemiscrotum with no cough reflex. Imaging revealed a perforated rectum and subsequent abscess formation, which tracked via an unusual anatomical route to present as scrotal swelling.

Introduction McKittrick-Wheelock syndrome is a rare entity characterized by chronic diarrhea, acute kidney injury, and hydroelectrolytic imbalance associated with a large rectal tumor, frequently a villous adenoma. Case report A 69-year-old male with chronic diarrhea with mucus. He underwent a colonoscopy with biopsies, reporting adenocarcinoma of the rectum in situ, and underwent a robot assisted intersphincteric resection with colo-anal anastomosis and a protecitive ileostomy. Discussion Described in 1954, this syndrome is manifested by electrolyte imbalance and acute renal injury secondary to diarrhea associated with a rectal villous adenoma, often with long lasting symptoms. The most frequent symptom being watery diarrhea with mucus. The definitive treatment consists of surgical resection. Conclusion Although this is a rare pathology, it should be considered as a differential diagnosis in cases of chronic diarrhea associated with water and electrolyte disorders.

Objective To investigate the characteristics and risk factors associated with regional lymph node metastasis in colorectal neuroendocrine neoplasm. Methods The clinical and pathological data of 79 patients with colorectal neuroendocrine neoplasm were retrospectively analyzed. The risk factors of regional lymph node metastasis were evaluated by multifactor Logistic regression analysis. Results The incidence of regional lymph node metastasis was 30.4% (24/79), among which para-intestinal lymph node metastasis was in 14 cases, mesenteric lymph node metastasis in 6 cases, and mesenteric root central lymph node metastasis in 4 cases. No patient was found to have skip metastasis and mesenteric root distant lymph node metastasis. The single factor analysis results showed that the tumor diameter, ulceration in mucous membrane, depth of invasion, pathological grading and invasion of lymphatic vessel were associated with regional lymph node metastasis in patients with colorectal neuroendocrine neoplasm (P<0.05). The multifactor Logistic regression analysis results showed that the tumor diameter, pathological grading and invasion of lymphatic vessel were was associated with regional lymph node metastasis in patients with colorectal neuroendocrine neoplasm (P<0.05). Conclusions The colorectal neuroendocrine neoplasm patients with larger tumor diameter, G2 and G3 of pathological grading and invasion of lymphatic vessel have higher incidence of regional lymph node metastasis; the mesenteric lymph node and para- intestinal lymph node should be paid special attention to in radical resection. Key words: Colorectal neoplasms; Neuroendocrine tumors; Neoplasm metastasis; Factor analysis, statistical; Retrospective studies